Chapter 6: Home care bound

Prime Minister Mr Lee Hsien Loong addressing the nation on 21 October 2021 to explain why we had to prepare for living with endemic COVID-19.

Source: MCI

Introduction

After a year of combating the disease with stringent infection control measures, the Government began preparing Singaporeans for living with endemic COVID-19. More was now known about the disease and, more importantly, a high percentage of the population was now vaccinated. The new approach was to conserve critical hospital resources to ensure that high-risk cases and the acutely unwell would have a high level of medical care when needed. The primary providers of medical care for mild COVID-19 cases would be community doctors and recovery at home would be the default.

A mindset shift was also needed — COVID-19 patients with mild symptoms could recover from home safely, allowing limited healthcare resources to be allocated to more severe cases. Learning to live with endemic COVID-19 would also allow Singapore to open its economy and borders.

So, on 30 August 2021, MOH launched a pilot Home Recovery Programme (HRP) for 21 mildly ill COVID-19 patients to recover at home instead of in hospital or CCFs, after ensuring that their household and social conditions were suitable. A small team from MOH served as dedicated Home Recovery Buddies to the patients. This small-scale pilot programme was a success.

MOH initiated a pilot programme on 30 Aug 2021 for 21 mildly ill COVID-19 patients to recover at home.

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But then COVID-19 cases began rising rapidly with the emergence of the more infectious Delta variant. This was a time of high anxiety for Singaporeans as Delta was more virulent than the Alpha, Beta and Gamma variants prevalent up to that time. Those with mild respiratory symptoms rushed to Accident & Emergency departments, and many who feared passing the virus to family members wanted to be housed at CCFs. Fortunately, the number of serious cases requiring oxygen supplementation or Intensive Care Unit (ICU) treatment was mitigated by the population's high vaccination rate. But the high total case count made it urgent to implement Home Recovery as the default mode for COVID-19 patients who were mildly ill.

Singapore's Covid-19 outbreak rise in daily reported infections

Infection numbers rose in September 2021 because of the Delta strain.

Source: MOH COVID-19 Statistics

The programme for home recovery had to be expanded nationwide at short notice, and the MOH team faced difficulties coping with the sudden surge in cases. The public's anxiety and frustration grew when those recovering at home or living with a COVID-19 patient could not get information from the authorities on what they should do. MOH's dedicated hotline could not handle all the daily calls. There were delays in the onboarding and discharge processes for COVID-19 patients. Those who had recovered were still being denied “Safe Entry” to workplaces and public amenities. There was also a growing need to cater to groups with medical and special needs, such as pregnant, paediatric, immunocompromised, disabled and palliative care patients. On top of these problems, the Microsoft Excel and email-based IT systems tracking the transfer of patients to suitable medical facilities could not cope with the increase in cases.

Standing up the Home Recovery Task Group

COL Tong Yi Chuen chairing a meeting in the Home Recovery Task Group.

Source: MINDEF

It was under those circumstances that the SAF's Home Recovery Task Group (HRTG) was set up. The mission was clear: as Singapore transitioned to living with COVID-19 as an endemic disease, HRTG would help MOH to strengthen their home recovery system so that all population groups covered by the HRP would be given the resources they needed for home recovery. HQ Singapore Combat Engineers was activated, and on the evening of 24 September 2021 Chief Engineer Officer COL Tong Yi Chuen alerted his team to their impending mission. They attended the first virtual briefing with MOH that night and placed their sub-units on standby. The next day, COL Tong and his core team reported at Harbourfront Centre and were briefed by MOH officials on the current situation and processes. They also discussed how HRTG could contribute, both immediately and over the longer term.

After a deliberate Mission Analysis, the team identified three focus areas for HRTG. First, it would quickly build up call centre capabilities to address public concerns. Second, it would review current processes and then implement a scalable HRP nationwide. Third, it would incorporate technology solutions so that there could be a more sustainable use of manpower and resources over the long term.

The next four days were spent planning HRTG's structure and manpower requirements, and coordinating training. HRTG was now ready to go, and on 29 September 2021 it started operations in the call centres. 48th Battalion Singapore Armoured Regiment (48 SAR) and 38th Battalion SCE (38 SCE) assisted in the Inbound Call Centre, fielding calls from the public about the HRP. The other sub-unit, 35 SCE, assisted in the Outbound Call Centre, which reached out to register COVID-19 patients on HRP and guided them through the home recovery process as Home Recovery Buddies.

Planners from the earlier task forces readily leaned forward to help HRTG HQ. COL Liew Kok Keong, who had served in the HSTF and was later deployed to MOTF as Chief-of-Staff, regularly shared his operational experience with HRTG. MAJ Nicholas Tjandra, who also was from HSTF, served in HRTG HQ as Head Anticipatory Operations Centre to do forward planning, monitor policy developments and their impact on HRTG operations, and foster partnerships with adjacent MOH and inter-Ministry task forces to strengthen the HRP. Like MOTF, HRTG tapped the collective experience of COVID-19 operations “veterans” across the SAF to rapidly build baseline capability and processes so that they would have more bandwidth to focus on novel and emerging challenges.

COVID-19 operations “veterans” across the SAF sharing their operational experiences with the HRTG Command Team, comprising representatives from the SAF and MOH's Case Management Task Group and Quarantine Operations Task Group.

Source: MINDEF

In parallel, resources and expertise from across the SAF and many government agencies were pooled so that there was data for the HRTG to measure its effectiveness. The team also worked with the RSAF Innovation SWiFT Office, GovTech's Open Government Products Office, and MOH's Information Fusion Centre to consider technology solutions so that the rapidly rising case numbers could be handled efficiently.

ME5 Jonathan Ng, a solutions architect in the RSAF Innovation SWIFT Office, briefing President Mdm Halimah Yaacob on the HRTG's call ticketing system.

Source: MINDEF

The RSAF Innovation SWiFT Office developed digital solutions that enabled large amounts of data from different parts of MOH to be seamlessly integrated, as well as an automated messaging system.

Source: MINDEF

HRTG handling the HRP effort would require an empathetic approach. Emotions were involved. The public was frustrated and their confidence in the Government's handling of COVID-19 was affected. The team's MOH partners were fatigued after their long battle with COVID-19 and disheartened by the public's harsh criticisms. It was necessary to be sensitive and show empathy to both the members of the public seeking help and advice, as well as the MOH colleagues who were hoping that HRTG could bring fresh perspectives and energy to the cause.

HRTG played the role of the supporting force that was “here to help” their MOH colleagues, especially as they would be taking the operational system back to MOH at the end of the HRTG deployment. The pilot programme had worked, so it was necessary to be sensitive to MOH's perspective on the HRP. It was with this sensitivity that the HRTG team set out to partner MOH in strengthening the established HRP processes, to scale it up much more extensively and rapidly than was originally planned for.

Putting patients first

NSFs manning hotlines at the Home Recovery Programme call centres.

Source: MINDEF

HRTG quickly identified the need for a critical shift in order to restore public confidence in the HRP. Instead of focusing on clinical outcomes, HRTG took a human-centric approach that was more relationship-based, handling one patient at a time. This patient-first mindset would drive all of HRTG's operations, especially in catering to vulnerable groups which required tailored and differentiated care, and in managing appeals and outliers. With fear and anxiety colouring the minds of COVID-19 patients and their families, HRTG knew that it was not enough to have a robust system. Empathetic communication with the patients was critical if the HRP was to be a success.

Home Recovery Buddies, comprising a mix of MOH and SAF personnel.

Source: MOH Facebook Page

The first order of business was to establish a Case Management System so that all cases could flow through and be handled appropriately. The existing call centres were beefed up so that check-ins could be expedited and there could be confidence in the accuracy of the information collected. Hotlines were expanded to meet the increased requests for assistance and redress. All the additional manpower came from full-time National Servicemen (NSFs) who were activated at short notice and quickly trained. An important part of their training was to learn how to speak with empathy to callers.

The first cohort was tasked to tackle the fast growing backlog of cases. They contacted COVID-19 patients who had recovered and those who were still ill and answered their questions, equipped with a list of Frequently Asked Questions (FAQs) cobbled together from the MOH websites. Although the FAQs were continuously updated and refined, the NSF Home Recovery Buddies inevitably had to grapple with information gaps while trying to answer some questions. Challenging cases were escalated to their superiors and policy guidelines clarified with their MOH colleagues. They helped one another by speaking to callers in their mother tongues when the callers could not communicate in English. Their empathy was tested by difficult callers, but they supported one another in managing difficult calls, working as a team, sharing information and tips for handling difficult callers. While their patience was tested when they were abused over the phone, they could understand the fear and anxiety of the callers and this helped them to stay calm and professional.

Home Recovery Buddy CPL Luth Danish at work.

Source: MINDEF

HRTG also had to deal with patients who were frustrated over being passed from one agency to another during the home recovery process. To mitigate the problem, HRTG implemented Zendesk, a centralised cloud-based system to manage HRP patients' journey from notification to discharge. The design of Zendesk placed the patient's experience at the heart of the system, and allowed HRTG to follow up efficiently with patients throughout the process, including on their unique needs and requests. This was especially important for patients who needed customised care by social agencies. SMS notifications allowed all patients to be onboarded and reminded of medical follow-ups. With Zendesk, no case would fall between the cracks when transiting between Cells and Centres.

The Zendesk interface.

Source: MINDEF

It soon became clear to HRTG that it was not possible to manage every case in the same way, as patients had many different social and medical needs. The team implemented a differentiated care approach.

Patients identified as needing “Basic Care” were a majority; they were well supported and needed only basic information and access to medical resources. Those identified as needing “Enhanced Care” were from vulnerable and high-risk patient groups with more medical or social needs, such as the elderly, pregnant women and children. Significant efforts were made to ensure that such patients were not left out in the triage or appeal process, and would be given greater attention and resources through the Care Management Centre established by HRTG.

Redesigned Home Recovery Programme

The Care Management Centre was formed when Ms Teoh Zsin Woon, Second Permanent Secretary, Public Service Division (PSD), offered HRTG resources and expertise for social outreach to vulnerable groups. The centre set up inter-agency partnerships to support vulnerable patients. Dedicated volunteers from PSD and the Silver Generation Office made daily checks on elderly patients. Community partners, such as People's Association, the Agency for Integrated Care and Ministry of Social and Family Development (MSF) helped PSD volunteers in providing support for HRP patients at the constituency level. For patients with special needs, HRTG worked with MOH to expand HRP support to groups such as the sensory-impaired, illiterate or handicapped individuals. The cooperation with relevant handicap associations and literacy foundations to improve patient support continued after the SAF handed the operations back to MOH.

HRTG sought to better understand the demographics of the Singapore population so that it could re-engineer to improve its support structure as needed. It worked hard to ensure that every patient received medical attention. The Data Management Centre, which was set up to help HRTG make better decisions using data on the HRP landscape, put in great effort to ensure that all patients were accounted for. Using the SAF Action Learning Process, every HRTG centre was constantly cross-learning and reviewing its processes whenever there were unique cases.

SV1 Lim Ai Buay Ivy from the SAF Volunteer Corps in the Data Management Team, working on updating data in time for quick analysis.

Source: MINDEF

HRTG also reviewed the process for appeals, and established an Appeals Centre to better manage patients who were not eligible for HRP but who wished to recover at home. The Appeals Centre had to carefully balance between the patient's autonomy and risks to public health. Managing appeal cases was a complex operation requiring a fine balance of sensitivity and firmness. More experienced civil servants from across PSD staffed the Appeals Centre, and swiftly attended to the backlog and surge in appeals.

Click HERE to view the story of a COVID-19 patient on the Home Recovery Programme.

Delivering mission outcomes

HRTG's work on redesigning the HRP for nationwide implementation was an important part of the WoG effort to transition Singapore to a state of living with endemic COVID-19. There were four phases in HRTG's operations. In Phase I (29 September to 10 October 2021), HRP Call Centre operations were expanded to meet the surge in public queries and to quell anxieties. Phase II (11 to 24 October 2021) focused on setting up the patient support system. In Phase III (25 October to 7 November 2021), internal processes were streamlined and external linkages were strengthened to maximise operating efficiency and sustainability. Phase IV (7 to 22 November 2021) focused on the transition to steady state with home-based recovery and self-care as the norm.

HRTG fulfilled up to 99% of engagement requirements from HRP patients.

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Handing over the HRTG Operations to MOH.

Source: MINDEF

Over the eight and a half weeks of its operations, HRTG assisted over 69,000 Home Recovery Helpdesk callers and onboarded 106,003 COVID-19 patients in the HRP via call centres. At its peak, every day the call centres were onboarding up to 3,500 patients and maintaining a 99% hotline engagement rate in addressing questions from patients on HRP. This compared with 50 HRP patients being onboarded and 15% of queries being answered daily before HRTG came in to scale up the operation.

Taking an empathetic approach was a key factor for HRTG's success in rapidly scaling up the HRP to meet the demands and showing quick results from its operations. Showing empathy and sensitivity smoothened the working relationships with MOH and other government agencies at a time of great stress and anxiety. HRTG was then able to produce quick and efficient solutions to improve many aspects of the HRP, including customising to meet the diverse needs of patients. An empathetic touch also characterised the interactions between HRTG and the public and helped calm the public mood and restore confidence in the Government's handling of the COVID-19 pandemic.

HRTG's record

• 1,255 SAF personnel involved

• Onboarded 106,003 C+ patients

• 59 days in operation

• ~99% call engagement rate

• Over 69,000 helpdesk enquiries

• > 90% tele-consultation within 6 hours